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![4. Fear-based warnings
“[Our findings] suggest that the
TPD nicotine addiction e-cigarette
health warning may reduce
smokers' willingness to use, and
likelihood of purchasing an e-
cigarette.”
31
Cox S, et al Messages matter: The Tobacco Products Directive nicotine addiction health warning versus an alternative
relative risk message on smokers’ willingness to use and purchase an electronic cigarette. Addict Behav Reports, 2018](https://image.slidesharecdn.com/africathrexchange-bates-dec2022-final-221201132429-d730a363/85/African-Harm-Reduction-Exchange-Dec-2022-31-320.jpg)
Uploaded byClive Bates
African Harm Reduction Exchange - Dec 2022
The document discusses the concept of tobacco harm reduction and its critical role in addressing smoking-related health issues, emphasizing the need for effective regulation of smoke-free alternatives like e-cigarettes. It highlights the significant public health risks associated with smoking, the potential benefits of reduced-risk products, and the unintended consequences of regulatory measures such as bans and taxes on these alternatives. The author advocates for a balanced and innovative regulatory approach that facilitates access to safer products while discouraging smoking.
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African Harm Reduction Exchange - Dec 2022
- 1. Clive Bates Counterfactual 1 Nairobi 1December 2022 Science behind Tobacco Harm Reduction …and how it impacts policy development and regulation The Harm Reduction Exchange 2022
- 2. 2 I am aformer director of Action on Smoking and Health (UK) I have supported tobacco harm reduction since 1997 I have no competing interests with respect to the tobacco, e- cigarette, or pharmaceutical industries
- 3. Regulation for tobaccoharm reduction 1. The problem is smoking 3
- 4. Well researched tollof harm from smoking… Smoking prematurely kills around 8 million annually …more than obesity, alcohol, road accidents, drug misuse and HIV combined 4 Public Health England, Health Matters …similar to COVID-19, but every year
- 5. Smoking prevalence inAfrica – WHO (2021) 5 Published November 2021 South Africa Nigeria Ethiopia
- 6. Smoking prevalence inAfrica – WHO (2021) 6 Published November 2021 South Africa Ethiopia Nigeria
- 7. Declining prevalence butincreasing population will increase African share 7 Africa
- 8. Regulation for tobaccoharm reduction 1. The problem is smoking 2. Smoke-free alternatives 8
- 9. “People smoke for thenicotine but die from the tar” (1976) Professor Michael Russell 1932-2009 The central insight in smoking and health 9 Russell MJ. Low-tar medium nicotine cigarettes: a new approach to safer smoking. BMJ 1976;1:1430–3
- 10. Smokeless tobacco Tobacco based Purenicotine based Heated aerosol Unheated Vaping products Heated tobacco products “Heat-not-burn” Items are not shown to scale Oral nicotine products 10
- 11. Royal College ofPhysicians – on relative risk "Although it is not possible to precisely quantify the long- term health risks associated with e-cigarettes, the available data suggest that they are unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower than this figure". 11 Royal College of Physicians. Nicotine without smoke: tobacco harm reduction London: RCP; 2016.
- 12. Department of Health(England) – on relative risk September 2022 12 McNeill et al. Nicotine Vaping in England, 2022 “…vaping poses only a small fraction of the risks of smoking”
- 13. Much lower Much lower Much lower Much lower Much lower Much lower The strongest evidencefor reduced harm is reduced exposure 13 Shahab L, Goniewicz ML, Blount BC, et al. Nicotine, Carcinogen, and Toxin Exposure in Long-Term E-Cigarette and Nicotine Replacement Therapy Users. Ann Intern Med 2017
- 14. Evidence from randomisedcontrolled trials 14 “There is high‐certainty evidence that e- cigarettes with nicotine increase quit rates compared to NRT”
- 15. Evidence for beneficialpopulation effect ‘triangulates’ • Also, user testimony • And… it is what you would expect!! 15 Professor Robert West, UCL. Presentation at SRNT-Europe 2019
- 16. Regulation for tobaccoharm reduction 1. The problem is smoking 2. Smoke-free alternatives 3. Policy and unintended consequences 16
- 17. The public healthmechanism 17
- 18. Royal College ofPhysicians – perverse unintended consequences 18 Royal College of Physicians. Nicotine without smoke: tobacco harm reduction London: RCP; 2016.
- 19. …if a risk-averse,precautionary approach makes e-cigarettes: • less easily accessible • less palatable or acceptable • more expensive • less consumer friendly • pharmacologically less effective • inhibits innovation … …then it causes harm by perpetuating smoking. Royal College of Physicians – perverse unintended consequences 19 Royal College of Physicians. Nicotine without smoke: tobacco harm reduction London: RCP; 2016.
- 20. 1. Prohibition ofvaping and other smokefree products
- 21. 1. Prohibition ofvaping and other smokefree products “Dr Harsh Vardhan received the award for spearheading the Government of India’s legislation to ban e-cigarettes and heated tobacco products in 2019.”
- 22. 1. Prohibition ofvaping and other smokefree products 22 Today, the country is faced with a greater challenge, that of illegal traffic in tobacco and its products. So long as the demand within the country persists, it will continue to fuel the illicit market that has expanded since the ban of its sale in early 2000. Unfortunately, as studies indicate, Bhutanese youth are at the centre of this growing illegal trade in tobacco and its products. WHO Office Bhutan: The Big Ban: Bhutan’s journey towards a tobacco-free society, 2019
- 23. 2. Banning e-liquidflavours 23
- 24. 2. Banning e-liquidflavours Tobacco Fruit Dessert or pastry Choc, sweets Russell et al. vaping flavour preferences Russell C, et al. Changing patterns of first e-cigarette flavor used and current flavors used by 20,836 adult frequent e-cigarette users in the USA. Harm Reduct J. BioMed Central; 2018 24
- 25. 2. Banning e-liquidflavours 25 • The intended outcome: abstinence from nicotine, vaping, smoking and any other vice • Using tobacco flavoured vape products instead of other flavoured products • Accessing flavoured vapes via an illicit supply chain (a black market) • Relapsing back from vaping to smoking – both teenagers and adults • Not switching from smoking to vaping and continuing to smoke • Continuing to smoke or to start smoking as an adolescent because parents or adult role models smoke instead of vaping • Using other tobacco or nicotine products – hand-rolling tobacco, smokeless tobacco, heated tobacco, or new nicotine pouches • Buying from foreign suppliers in person or via the internet and importing for personal use • Buying from foreign suppliers to resell to others through informal networks • Making and mixing their own flavours at home or buying or selling home-mixed flavours • Using vapes that are made to look tobacco flavoured but have other flavours • Using flavour agents for food, drink or aromatherapy for adding to unflavoured nicotine liquids • Using flavours made for vaping but ostensibly marketed for another purpose • Switching to cannabinoid (THC or CBD) vapes • Initiating smoking instead of initiating vaping • Adopting another risk behaviour that may be worse
- 26. Friedman AS. ADifference-in-Differences Analysis of Youth Smoking and a Ban on Sales of Flavored Tobacco Products in San Francisco, California. JAMA Pediatrics. 2021 2. Banning e-liquid flavours Teenage smoking increased following an e-cigarette flavours ban in San Francisco Past-30-Day Smoking Trends Among High School Students Younger Than 18 Years
- 27. 3. Banning advertisingof vapes 27
- 28. 3. Banning advertisingof vapes 28
- 29. 3. Banning advertisingof vapes 29 Don’t be socially irresponsible Don’t target or feature children Don’t confuse e-cigarettes with tobacco products Don’t make health or safety claims Don’t make smoking cessation claims Don’t mislead about product ingredients Don’t mislead about where products may be use Set standards avoid bans
- 30. 4. Fear-based warnings Thisproduct contains nicotine which is a highly addictive substance. 30 Required by EU Tobacco Products Directive 40/14/EU
- 31. 4. Fear-based warnings “[Ourfindings] suggest that the TPD nicotine addiction e-cigarette health warning may reduce smokers' willingness to use, and likelihood of purchasing an e- cigarette.” 31 Cox S, et al Messages matter: The Tobacco Products Directive nicotine addiction health warning versus an alternative relative risk message on smokers’ willingness to use and purchase an electronic cigarette. Addict Behav Reports, 2018
- 32. This product islikely to be at least 95% safer than smoking cigarettes No product is completely safe, but use of this product is much less harmful than smoking 4. Fear-based warnings 32
- 33. 5. Taxing saferproducts
- 34. 5. Taxing saferproducts • Reduce teen e-cigarette use by 2.7 percentage points, but that 2 in 3 teens who do not use e- cigarettes due to the tax would smoke cigarettes instead. • ….approximately a half million extra teenage smokers overall. • … raise the number of daily adult cigarette smokers by 2.5 million nationally and reduce adult e-cigarette users by a similar number. • For every e-cigarette pod eliminated by an e- cigarette tax, more than 5.5 extra packs of cigarettes are sold instead Congress: raise e-cigarette taxes to a level comparable to cigarette taxes…
- 35. 5. Taxing saferproducts
- 36. The solution: Risk-ProportionateRegulation Measure Cigarettes, hand-rolling tobacco and other combustibles Taxation Relatively high taxes Advertising Prohibit other than within trade Warnings Graphic warnings depicting disease Public places Legally mandated controls Plain packaging Yes Ingredients Control reward-enhancing additives Age restrictions No sales to under-21s Internet sales Banned Product standards Control risks and reduce appeal 36
- 37. The solution: Risk-ProportionateRegulation Measure Cigarettes, hand-rolling tobacco and other combustibles Vaping, heated tobacco smokeless and oral nicotine Taxation Relatively high taxes Low or zero tax (sales tax only) Advertising Prohibit other than within trade Control themes and placement Warnings Graphic warnings depicting disease Messages encouraging switching Public places Legally mandated controls Up to the discretion of the owner Plain packaging Yes No Ingredients Control reward-enhancing additives Blacklist material health hazards Age restrictions No sales to under-21s No sales to under-18s Internet sales Banned Permitted with age controls Product standards Control risks and reduce appeal Control risks 37
- 38. Regulations for tobaccoharm reduction 1. The problem is smoking 2. Smoke-free alternatives 3. Policy and unintended consequences 4. Innovation (and its enemies) 38
- 39. A technology transition- cars
- 40. A technology transition- electricity
- 41. Innovation and itsenemies… “Claims about the promise of new technology are at times greeted with skepticism, vilification or outright opposition—often dominated by slander, innuendo, scare tactics, conspiracy theories and misinformation. “The assumption that new technologies carry unknown risks guides much of the debate. This is often amplified to levels that overshadow the dangers of known risks.” Juma C. Innovation and Its Enemies: Why People Resist New Technologies. Oxford, New York: Oxford University Press; 2016.
- 42. Thankyou! Counterfactual clivedbates@gmail.com www.clivebates.com @clive_bates 1. The problemis smoking 2. Smoke-free alternatives 3. Policy and unintended consequences 4. Innovation (and its enemies) Regulation for tobacco harm reduction
Editor's Notes
- #11 Vaping products Top row shows: 1st generation cig-a-likes 2nd generation ego or ‘pen’ type devices 3rd generation tanks / mods type Bottom row shows Large electronic hookah Small shisha pipes Electronic pipe … there are many other configurations Heated tobacco products – sometimes referred to as heat-not-burn to distinguish between combustible products Shows the iQOs, Ploom and Glo products Novel nicotine products - shows Nicoccino – a nicotine containing film Zonnic – a range of nicotine products – lozenges, gum etc Voke – a cold aerosol (approved but not marketed) Niorette – cross-over NRT Smokeless tobacco Snus Moist snuff Tobacco-based lozenge